Case Report

Diffuse Otitis Externa

Background The prevalence varied in different
Otitis externa is an inflammatory region depending on factors such as risk factor
condition of the external ear canal, with or and geographical location. 3,5,
without infection. External otitis are caused by The factors that facilitate inflammation
fungal, bacterial and viral infections. 1,2 of the outer ear are changes in pH in the ear
Otitis externa is found in all regions of canal, which are usually normal or acidic.
the United States, occurring in 4 of every 1000 When pH becomes alkaline, protection against
people annually. The infection is believed to be infection decreases. In warm and humid
more prevalent in hot and humid conditions conditions, germs and fungi are easy to grow.
such as prevail during the summer months, Other predisposing factors include ear
presumably because participation in aquatic manipulation with a cotton bud (cotton swab),
activities is higher. Acute, chronic, and anatomic obstructions of the ear canals
eczematous Otitis Externa are also common. (stenosis, impacted cerumen), hearing aid or
The international frequencies of OE have not ear plug use, diabetes or an
been fully determined; however, the incidence immunocompromised state, skin condition
is increased in tropical countries.3 such as eczema, seborrhea, and psoriasis and
Although the infection can affect all age excessive sweating. Acute otitis externa also
groups, Otitis externa appears to be most associated with water exposure (e.g.,
prevalent in the older pediatric and young adult recreational water activities, bathing, and
population, with a peak incidence in children excessive sweating). Therefore, diffuse otitis
aged 7-12 years. A single epidemiologic study externa commonly called swimmer’s ear. 2,5,6,7
from the United Kingdom found a similar 12- In one study, 91% of cases of Acute
month prevalence for individuals aged 5-64 Otitis Externa were caused by bacteria. Otitis
years and a slight increase in prevalence for externa is most often caused by a bacterial
those older than 65 years.4 This was postulated pathogen, there are pseudomonas, strepococci,
to occur secondary to an increase in staphylococci. Aureus, bacteroides, and other
comorbidities, as well as an increase in the use varieties include fungal Otitis Externa
of hearing aids, which may cause trauma to the (otomycosis) and eczematoid (psoriatic) Otitis
external auricul canal.3 Otitis Externa affects Externa.8 Fungal Otitis externa may result from
both sexes equally. No racial predilection has overtreatment with topical antibiotics or may
been established, though people in some racial arise de novo from moisture trapped in the
groups have small ear canals, which may EAC. It is caused by Aspergillus, Candida, and
predispose them to obstruction and infection. 3,4 other organism have also been isolated.9

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 The symptoms of otitis externa in of dear or slightly cloudy secretion may be seen
general are pain, fullness, itching, and hearing in the canal. As pain and itching increase, the
loss are the four major symptoms of otitis patient progresses to the moderate stage, in
externa, although not every patient has each the which the canal shows more edema and a
symptom. Other symptoms are otorrhea and thicker more profuse exudate. Further
1,2
pain when opening the mouth. From progression of the inflammation the absence
physical examination depend on staging of treatment produces the severe inflammatory
inflammation. Pre-inflammatory is found mild stage. Characterized by increased pain and
erythema, edema. Acute inflammatory stage obliteration of the lumen of the canal. A
could be found tragus pain, erythema, edema, profuse, purulent exudate and edema of the
discharge. Chronic inflammatory could be canal skin may obscure the TM. In addition,
thickening, flaking of canal skin small white papules are often visible on the
eczematization ulceration. Supporting surface of the canal skin. P. aeruginosa or
examination can be done with bacterial another gram-negative bacillus can almost
culture.1,6 always be cultured at this stage. In the severe
The clinical course of external otitis stage, the physician often sees evidence of
may be divided into the following stages: pre- extension of infection beyond the canal to
inflammatory, acute inflammatory (can be involve the adjacent soft tissues and cervical
mild, moderate, or severe), and chronic lymph nodes In the chronic inflammatory
inflammatory. Typically, the pre-inflammatory stage, the patient experiences less pain but
stage begins when the stratum corneum more profound itching. The skin of the external
becomes edematous due to the removal of the canal is thickened, and superficial flaking may
protective lipid layer and acid mantle from the be seen. The auricle and concha often show
canal, resulting in plugging of the secondary changes such as eczematization,
apopilosebaceous unit. As obstruction lichenification, and superficial ulceration. This
continues, a sense of fullness and itching condition is likened to eczema and may range
begins. The disruption of the epithelial layer from mild drying and thickening of the canal to
allows invasion of bacteria that either reside in complete obliteration of the external canal by
the canal or are introduced on foreign objects chronically infected, hypertrophic skin.1,6
inserted into the canal, such as a cotton swab or Classification of otitis externa
a dirty fingernail. This produces the acute according to time is divided into acute, and
inflammatory stage, which is accompanied by chronic otitis externa. Acute otitis externa is
pain and tenderness of the auricle. In the divided into 2, furuncle otitis externa and
earliest stage, the skin of the EAC shows mild diffuse otitis externa.2,10
erythema and minimal edema. A small amount

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 The four fundamental principles in the the precipitating factor can be avoided.
treatment of external otitis in all stages are However, otitis externa often recurs if ear
frequent and thorough cleaning, judicious use hygiene is not maintained, there is a history of
of appropriate antibiotics, treatment of certain diseases such as diabetes which
associated inflammation and pain, and complicates the healing of otitis itself, and does
recommendations regarding the prevention of not avoid the trigger factor properly.11
future infections. Aural toilet can be done by
dry mopping, suction clearance, irrigating the Case Report
canal with warm, sterile normal saline or A 26-year-old male patient came to the
hydrogen peroxide, removal of obstructing ENT Polyclinic of RSUP Dr. Sardjito Hospital
cerumen or foreign object. Local steroid drops with the main complaint of the right ear feels
help to relieve edema and erythema, and pain, feels lumpy, and feels full since 3 days
prevent itching. The use of analgesics in acute ago. Complaints are also accompanied by
otitis externa is to provide an adequate pain decreased hearing, a little yellow discharge and
relief. Pain caused by AOE can be intense and pain when chewing food. Other complaints
severe, because the highly sensitive periosteum such as spinning dizziness and ringing in the
of the underlying bone is in close proximity to ears are denied by the patient. The patient is not
ear canal skin, especially in the deeper portion coughing with a cold. Complaints in the nose
of the canal. Patient should be educated to resist and throat are denied. Patients have a history of
manipulation to minimize ear trauma, frequent ear cleaning with a cotton bud and
minimize the introduction of water or moisture have a habit of swimming 1 time a week.
into the ear, insertion of hearing aids or ear The patient has no history of diabetes mellitus
phones should be limited until pain and or allergies. There is no history of discharge
discharge have subsided.1 came out from both ears.
Complications of otitis externa are From the general examination it was
pericondritis (inflammation of the ear lobe found that the general condition of the patient
cartilage that occurs when a trauma or looked good, consciousness was compos
inflammation causes serum or pus effusion mentis, blood pressure was 104/70 mmHg,
between the pericondrial lining and outer ear heart rate was 76x / minute, breathing was 16x
cartilage), cellulitis (this can occur as a result / minute, temperature was 36.7⁰ C.
of skin trauma or secondary bacterial infection In the physical examination of the outer
from open wounds, such as pressure sores, or ear there is no deformity, the right ear is painful
may be related to skin trauma).1 when withdrawal is performed, pain increases
The prognosis of otitis externa can when the tragus is pressed. On otoscopy
generally be cured if treated immediately and examination of the right ear, Pthere are edema

3
ear canals, hyperemia and there is a yellow physical examination, and an otoscopy
liquid. Examination of the tympanic membrane examination is appropriate.
is difficult to assess. There are no foreign Acute otitis externa therapy is based on
objects in the ear canal. Other tests include the the stage. External otitis in all stages are
left ear, nose and mouth within normal limits. frequent and thorough cleaning, judicious use
The patient is diagnosed with External of appropriate antibiotics, treatments of
Otitis Diffuse Acute, based on the onset of the associated inflammation and pain, and
day, symptoms and signs of inflammation in recommendations regarding the prevention of
the right ear canal during physical examination. future infections. In any stage of infection,
In patients performed aural toilet procedures, thorough cleaning is a priority. Meticulous
installation of suffratul tampons and given drug debridement of exfoliated debris, purulence,
therapy in the form of diclofenac potassium 50 and cerumen will do as much if not more than
mg given 2 times a day, patients were also simply placing the patient on ear drops. In the
given cifroflocaxin 500 mg antibiotics given 2 pre-inflammatory stage, a complete cleaning
times a day. Patients are also given education, may be all that is required. In the absence of
not to manipulate the ear canal. In this patient, purulence, a brief course of an acidifying drop
an evaluation of 2 days was repeated for the such as aluminum sulfate-calcium sulfate
release of sufratul tampons on the right ear. (Domeboro) is efficacious in discouraging
bacterial or fungal growth. Treatment of the
Discussion acute inflammation stage varies with the extent
From the patient history, there are 3 of disease. In the mildest form, cleaning as
major symptoms and minor symptoms, the above is indicated. An antibiotic otic drop is
major symptoms are ear pain, fullness, and recommended to cover what is probably a
hearing loss. This minor symptom is a yellow Pseudomonas infection. At this stage edema of
discharge. Major and minor symptoms in the EAC should not be severe, and the patient
patients include symptoms of otitis externa, the should be able to instill drops into the ear by
symptom that have been felt since three days tilting the head to the side or by lying down
ago is including acute onset. From the results with the involved ear upright.
of physical examination found tragus In the moderate stage of inflammation,
tenderness, on examination otoscopy ear canal edema of the canal may interfere with the
edema, hyperemia and there is a yellow liquid. instillation of drops. The physician should then
From the results of the physical examination it insert a wick into the canal and instill drops on
is very clear that the diagnosis of this patient is it. Often the canal may accommodate two or
acute diffuse otitis externa. So the diagnosis in even three week. As the wick expands, it
these patients is based on anamnesa results, presses the soft tissues and periosteum toward

4
the non-distracted position this alone may cephalosporins. The fluoroquinolone
relieve pain. All instrumentation of the ear is antibiotics are effective against Pseudomonas
best done under the microscope. The wick is species. In children under 12 years old, one
removed by the physician at the time of should check with the pediatrician prior to
reexamination. If the edema has not been starting oral fluoroquinolones. Warm soaks
significantly reduced, repacking is indicated. (normal saline or a mild aluminum sulfate-
Antibiotic drops should be continued for at calcium acetate solution) are also useful in the
least 2 to 3 days after the cessation of pain. treatment of the crusting and edema involving
itching, and drainage so that complete the auricle and surrounding skin. Culture of the
eradication of infection may be ensured. In the canal for aerobic bacteria and/ or fungi is
moderate stage, an oral analgesic is often indicated only for the severe stage or for
prescribed because pain can be pronounced. patients who have previously been treated
Caution the patient to avoid manipulation of the without resolution. Treatment is generally
canal. Swimmers should be taught to towel dry continued for 10 to 14 days if there is a good
the concha and lateral canal, to shake water out response. In rare patients who do not respond
of the canal, or to instill an acidifying drop after to this regimen. hospitalization. vigorous daily
swimming. If the infection has not spread local care, repeat culturing, and intravenous
beyond the boundaries of the external canal, the antibiotics are indicated.
use of oral antibiotics will be of little if any From the results of the otoscopy
value. A final office visit is important to ensure examination the patient was found to have ear
that the infection has completely resolved and canals edema, erythema, and yellow fluid.
the canal is back to its normal state. From these data patients are included in the
In the severe stage, infection usually moderate stage. So the principle of therapy in
extends beyond the limits of the canal. In these patients is evacuation of discharge,
addition to the cleaning, packing, and use of tampons with antibiotics or can be given ear
antibiotic drops as discussed previously, attend drops.
to any soft tissue involvement by using an oral
antibiotic with broad-spectrum coverage. Resume
Successive generations of the cephalosporins A 26-year-old male patient, with a chief
widen gram-negative coverage at the expense complaint of pain in the right ear, feels
of gram-positive coverage. In addition to anti- congested, and feels full. Patients diagnosed
Pseudomonas ear drops, common choices of with External Otitis Diffuse Acute. Patients
oral antibiotics are one of the antipseudomonal were treated with aural toilet, installation of
fluoroquinolones such as ciprofloxadn or sufratul tampon and given drug therapy in the
levofloxacin, antistaphylococcal penicillins, or form of 50 mg diclofenac potassium given 2

5
times a day, the patient was also given 6. Jung K. T. Timothy; Jinn, Hoon, Tae,
cifroflocaxin 500 mg antibiotics given 2 times Disease of External Ear. In :
a day. Patients are educated so as not to Ballenger’s Otorhinolaryngology Head
manipulate the ear canal such as cleaning the and Neck Surgery Sixteenth Edition,
ear canal using a finger or cotton bud again. Chapter 8,BC Decker.2003
Patients were recited for another 2 days 7. Bailey, Byron J.; Johnson, Jonas
evaluation T.;Newlands, Shawn D, Head & Neck
Surgery-Otolaryngology, 4th Edition,
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